B Rechel

Access to health care for Roma children in Central and Eastern Europe: findings from a qualitative study in Bulgaria

BackgroundDespite the attention the situation of the Roma in Central and Eastern Europe has received in the context of European Union enlargement, research on their access to health services is very limited, in particular with regard to child health services.Methods50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia.ResultsOur findings provide important empirical evidence on the range of barriers Roma children face when accessing health services. Among the most important barriers are poverty, administrative and geographical obstacles, low levels of parental education, and lack of ways to accommodate the cultural, linguistic and religious specifics of this population group.ConclusionOur research illustrates the complexity of the problems the Roma face. Access to health care cannot be discussed in isolation from other problems this population group experiences, such as poverty, restricted access to education, and social exclusion.

Impact of health reforms on child health services in Europe: the case of Bulgaria.

BACKGROUND In the last two decades, all countries in Europe have embarked on substantial health reforms, introducing new models of financing and provision of health services. Using Bulgaria as a case study, this article examines the impact of the reforms on child health services. METHODS This is the first of a series of papers drawing on a broader research on inequalities in access to child health services, using Bulgaria as a case study. Multiple methods and data sources were used, including a review of the literature and existing epidemiological data, 50 qualitative in-depth interviews and an analysis of regulatory documents. This article presents the findings of the documentary analysis. RESULTS Primary health services for children are now provided by general practitioners. Children are exempted from health insurance contributions and user fees and are formally entitled to free health care. During the first years of the reform general practitioners still had insufficient training in child health. Restrictions on the number of referrals to paediatricians and discontinuation of community services at a time when general practice was not well established, undermined access to quality care. CONCLUSION While many of these issues have been subsequently addressed, the reform process was far from linear. Challenges remain in ensuring access to quality child health services to the rural population and marginalized groups, such as the Roma minority and children with disabilities. Throughout Europe, health reforms need to be based on solid evidence of what works best for improving quality of and access to child health services.

The Soviet legacy in diagnosis and treatment: Implications for population health

This article reviews diagnosis and treatment in the Commonwealth of Independent States in three clinical areas: tuberculosis, substance misuse, and neurological disorders in children. While the specific problems in each of these areas differ greatly, commonalities emerge, pointing to the continued influence of the Soviet past. Although progress in developing evidence-based medicine is being made, the isolation of Soviet science from Western developments has resulted in the widespread use of outdated diagnostic procedures and treatment protocols, while finance mechanisms still encourage unnecessary hospitalizations and treatments. A hierarchical medical system, as well as underdeveloped patient rights and medical ethics, mean that patients have little information and ability to participate in decision-making. The continued use of outdated approaches to diagnosis and treatment contributes to poor population health outcomes in the region.

Perceived barriers to the development of modern public health in Bulgaria: a qualitative study.

ObjectivesThis qualitative investigation documents Bulgarian perspectives on public health following its accession to the European Union (EU) and explores perceived obstacles to the modernization of public health sciences to more effectively address the country’s high rates of premature avoidable mortality.Methods28 semi-structured interviews were conducted throughout Bulgaria in April 2007 with Bulgarian academics, clinicians, policymakers and students in Sofia, Varna and Pleven. Full transcripts were subjected to formal thematic analysis.ResultsRespondents identified various barriers to the development and modernization to public health infrastructures in Bulgaria that were classified by four key interlinked themes: (1) institutional and political, (2) financial, (3) dearth of local epidemiological studies, and (4) insufficient public health capacity.ConclusionsThis study is the first to explore specific perspectives and beliefs regarding barriers to the development, modernization, and utilization of public health sciences in Bulgaria. Although the reorientation and strengthening of public health institutions are unlikely to proceed without resistance, optimism for improvement in this field exists now that Bulgaria has joined the EU.